INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Victory Treatment Group LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #2 was hired as a clinical supervisor on November 5, 2024 and was due to have the communicable disease trainings no later than November 5, 2025. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #3 was hired as a counselor on November 5, 2024 and was due to have the communicable disease trainings no later than November 5, 2025. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Both employee #2 and #3 have taken the required TB/STD Training on February 24, 2026.
The Facility Director will ensure that employees receive the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of staff schedules and personnel records, the facility failed to provide sufficient number of staff persons trained in CPR and first aid training, so that at least one person trained in these skills is onsite during the project's hours of operation.
There was no one trained in CPR present at the facility on December 12, 2025 from 12:00 am to 5:00am, December 13, 2025 from 12:00am to 8:00am, December 19, 2025 from 12:00 am to 5:00am, December 20, 2025 from 12:00 am to 8:00am, December 26, 2025 from 12:00am to 8:00am, December 27, 2025 from 12:00 am to 8:00 am, January 2, 2026 from 12:00am to 8:00 am, and January 3, 2026 from 12:00am to 8:00am.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff member who was present per the observation has renewed their CPR and First Aid Training on January 27, 2026.
The Facility Director will ensure that staff is trained in CPR and first aid and ensure that there is at least one person trained onsite during our operational hours. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on January28, 2026, the facility failed to ensure cold food was at or below 40F. The facility did not have a mechanism to ensure the temperature of cold food was at or below 40F in the staff and client's refrigerators.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
A mechanism was placed in facility refrigerator and client refrigerator on the day of inspection.
The Facility Director will ensure that a mechanism to ensure the temperature of the cold food is at or below 40F is in the refrigerator. |